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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54050 | 5 May 2019 08:18:00 | 10 CFR 30.50(b)(2) | Stuck Radiography Camera Source | The following information was received via E-mail: At approximately 0018 YDT on 5/5/2019, a Kakivik radiographic crew working in Alpine, Alaska on drill site CD-4, could not retract a source under normal conditions. Once this was identified the crew initiated emergency procedures by establishing 2mR boundaries and making notifications per O&E procedures. The crew was using a QSA Global 880D device with a model A424-9, 44.6, Ci Ir-192 source along with a 10HVL collimator. The crew had made 15 exposures. The last exposure is when the Radiographer noticed a sudden stop from the drive cable during his retraction and that is what initiated the emergency procedures. At approximately 0308 YDT the source was locked and secured in the 880D device. It was determined that the guide tube was draped low in a 'W' shape at the guide tube extension point which was preventing the source from coming in under normal conditions. The cranks were straightened and a pole was used to raise the guide tube at the extension connection point and the source was retracted in normal conditions. No one was over-exposed and the boundaries were placed at such a distance that the crew and public were safe. It was a four man crew, two of whom received 0mR and the Radiographer and Assistant received 11mR and 8mR, respectively. The emergency response team members received 1mR (two of them) and 3mR (two of them). | ||
| ENS 52691 | 18 April 2017 10:30:00 | 10 CFR 30.50(b)(2) | Failure of the Radiography Camera Locking Mechanism | After performing a routine exposure with a QSA model 880D (serial number D8127) camera containing a 133 curie Iridium-192 source, the source was cranked back into the camera. The radiographer noted that the outer locking mechanism did not lock. The source was let out again then retracted. The camera locking mechanism worked the second time. The locking mechanism did not work because of the icing condition. The radiography camera was placed in a warmer environment, and the locking mechanism was retested. No overexposure occurred during the event. | ||
| ENS 52596 | 7 March 2017 05:00:00 | 10 CFR 30.50(b)(2) | Radiography Camera Source Did Not Lock in the Shielded Position When Retracted | While performing radiography in arctic conditions at the Alpine oil field between ice roads CD1 and CD5, the radiographer retracted the source after an exposure and failed to recognize that the source was not in the locked position. Prior to moving the radiography camera to the next area for an exposure, the survey indicated the source was in the shielded position. The radiographer picked up the camera to take it to the next weld location for an exposure. When the radiographer placed the radiography camera down, his dosimeter rate alarm sounded, his survey meter (on the 10 scale setting) was off scale and his pocket dosimeter was off scale. It is believed that during the moving of the camera to the next shot location the source came out of the fully shielded position. The exact time and distance of the exposure is not known. Calculations show that the radiographer may have received between 3.5R - 39R of exposure. The radiographer's dosimeter has been sent for processing and results are expected in approximately 2 days. The assistant radiographer was not in the direct vicinity and received no exposure due to this event. The radiography camera involved was a QSA Global Model 880D with a 84.6 Ci Ir-192 source.
The badge reading of the radiographer indicated that he received 452 mR exposure for the month therefore no overexposures occurred due to this event. Notified R4DO (O'Keefe), NMSS (McIntosh) and NMSS Events Notification email. | ||
| ENS 51582 | 1 December 2015 10:00:00 | 10 CFR 30.50(b)(2) | Radiography Camera Fails to Lock Source Automatically When Retracted | On 12/01/2015 at 0100 AST, a radiography crew was working in blizzard conditions at a job site located on the Kuparuk Oil Field, North Slope, Alaska. After finishing a camera exposure, the source was being retracted, but the automatic lock for the exposure device did not lock the source in the camera. One of the radiographers manually engaged the slide to lock the source in the camera. No abnormal exposures were noted. | ||
| ENS 50990 | 13 April 2015 08:00:00 | 10 CFR 20.2202(b)(1) | Potential Overexposure to Radiographer | A radiographer dropped his film badge on the floor before his first exposure. The floor was approximately three feet below the collimator for a two minute exposure. After his second exposure, he found his film badge. The licensee's RSO had the film developed with a result of 14.069 Rem. The source was Ir-192 at 78.6 Ci. Estimated dose by the licensee and REAC/TS expected a dose of closer to one and a half Rem. The licensee is continuing his investigations because of this discrepancy. | ||
| ENS 48119 | 2 July 2012 07:45:00 | 10 CFR 30.50(b)(2) | Unable to Retract Source Into Radiography Camera | On July 1, 2012 at 11:45 pm, a radiography crew using remote access technology at the Kuparuk Oil Field on the North Slope of Alaska had the jig, collimator and guide tube dislodge and fall while cranking out the source. With the added weight of the connected jig and collimator, the guide tube ended up hanging straight down 30 feet above a platform floor, creating a sharp bend where the guide tube connects to the camera. The crew was not able to retract the source immediately after the accident. Kakivik's onsite Radiation Safety Supervisor and the RSO were immediately notified. The 2 mr/hr boundary was re-surveyed and adjusted. Constant surveillance and control of the boundary was maintained. Per guidance from the Kakivik's emergency procedures and RSO, the exposure device was to be lowered by ropes onto a suitable working surface. During the camera decent, the guide tube came in contact with piping and was straightened sufficiently to allow the source to be safely cranked into the fully shielded and secured position while still suspended from the ropes. The source was fully shielded within the exposure device by 2:13 am July 2nd. The operation to lower the camera to straighten the guide tube and crank in the source to the fully shielded position took approximately one minute. No exposure to the public or overexposure to Kakivik employees or unauthorized entry into the restricted area was made. All the radiographic equipment was inspected after the accident. The ball connector at the end of the crank drive cable was bent and was replaced. The outside of the guide tube was damaged and taken out of service. The camera including the source pigtail connector was not damaged and was returned to service. After investigation, the cause of the incident was determined to be the improper use of a magnetic jig that was attached to a surface that did not have sufficient force to hold the combined weight of jig, collimator, guide tube and source. The corrective actions taken to prevent recurrence included writing a company policy that clearly states that a radiographer may not use magnetic jigs to support the guide tube and collimator unless it is also supported with ratchet straps or a chain wrench or unless the magnetic jig is being used on a flat steel floor surface. This policy will be required to be read and adhered to by all current and new radiographers. This incident will be reviewed with all the Kakivik radiographers and assistants by the RSO or RSS. There were no injuries as a result of this event and there were no overexposures to members of the public or employees. | ||
| ENS 47428 | 10 November 2011 20:10:00 | 10 CFR 30.50(b)(2) | Radiography Camera Source Fails to Completely Retract | On November 10th, the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6774). During the shift, the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated. The 2 mR/hr boundary was reconfirmed and the Foreman and Supervisor were notified. The camera was surveyed and noted as being safe to transport. The camera was tagged out and placed in the Permanent Storage facility. A trained radiographer removed and cleaned the locking system. The locking system was successfully reinstalled. The camera has been returned to service. Exposure Device: Industrial Nuclear IR-100 Device S/N: 6774 Source S/N: 70129B Source Activity: 63.4 curies Source Type: Ir-192 Source Model # QSA 87703 There was no exposure to the crew or the general public during this incident. See similar events: 47418, 46533, 46323, 46233, 46052, 46051, 45669, 45648, 45609, 45544, 45524, 45496, 45469, 45384. | ||
| ENS 47418 | 6 November 2011 07:00:00 | 10 CFR 30.50(b)(2) | Radiography Camera Source Lock Malfunction | A radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunction of the locking system on an INC IR-100 exposure device. After completing radiography activities, the source was cranked in however, the source was still 1/4 to 1/2 inch from the fully retracted position. There were no abnormal readings observed and the key was turned to the locked position. The crew has been trained for this type of situation. They dismantled the lock, cleaned it, rebuilt it, and retracted the source to its fully retracted position. Exposure Device: Industrial Nuclear IR-100 Device S/N: 6774 Source S/N: 70129B Source Activity: 80 curies Source Type: Ir192 There was no exposure from this event.
The following report was received via fax: On November 5th, the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6774). During the shift, the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated. The 2 mR/hr boundary was reconfirmed and the Foreman and Supervisor were notified. The camera was surveyed and noted as being safe to transport. The camera was tagged out and placed in the Permanent Storage facility. A trained radiographer removed and cleaned the locking system. The locking system was successfully reinstalled. The camera has been returned to service. Exposure Device: Industrial Nuclear IR-100 Device S/N: 6774 Source S/N: 70129B Source Activity: 63.4 curies Source Type: Ir-192 Source Model # QSA 87703 There was no exposure to the crew or the general public during this incident. Notified the R4DO (Hay) and FSME (Camper). | ||
| ENS 46533 | 11 January 2011 08:59:00 | 10 CFR 30.50(b)(2) | Locking Mechanism Malfunction on Radiography Camera | On January 10th, the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6631). During the shift the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated. The 2 mR/Hr boundary was reconfirmed and the night foreman was notified. The camera was surveyed and noted as being safe to transport. The camera was tagged out and placed in the permanent storage facility. A trained radiographer removed and cleaned the locking system. The locking system was successfully reinstalled. The camera has been returned to service. Exposure Device: Industrial Nuclear IR-100 Device SIN: 6631 Source SIN: 666928 Source Activity: 95 curies Source Type: Ir192 Source Model # QSA 87703 There was no exposure to the crew or the general public during this incident. | ||
| ENS 46323 | 10 October 2010 00:00:00 | 10 CFR 30.50(b)(2) | Locking Mechanism Malfunction on Radiography Camera | On October 9, the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunction of the locking system on an INC IR-100 exposure device. After completing radiography activities, the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated. The 2 mR/Hr boundary was reconfirmed and the Radiation Safety Supervisor was notified. A trained radiographer came to the site and removed the locking system and cleaned it. The locking system was successfully reinstalled. The camera has been returned to service. Exposure Device: Industrial Nuclear IR-100 Device S/N: 6631 Source S/N: P661 Source Activity: 61 curies Source Type: Ir192 Source Model # INC Model 32 There was no exposure to the crew or the general public during this incident. | ||
| ENS 46233 | 4 September 2010 08:00:00 | 10 CFR 30.50(b)(2) | Locking Mechanism Malfunction on Radiography Camera | On September 4th the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6631). At the end of the shift the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated. The 2 mR/Hr boundary was reconfirmed and the Radiation Safety Supervisor was notified. A trained radiographer came to the site and removed the locking system and cleaned it. The locking system was successfully reinstalled. The camera has been returned to service. Exposure Device: Industrial Nuclear IR-100 Device S/N: 6631 Source S/N: P661 Source Activity: 84 curies Source Type: Ir192 Source Model # INC Model 32 There was no exposure to the crew or the general public during this incident. | ||
| ENS 46052 | 29 June 2010 09:00:00 | 10 CFR 30.50(b)(2) | Lock Malfunction on a Radiography Camera | On June 29th (at approximately 0100), the radiography crew working the Alpine Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an Industrial Nuclear Corporation (INC) IR-100 exposure device (serial number 4814). During the night shift the locking mechanism on the exposure device would not operate properly. When the locking latch was depressed the source could not be moved to the exposed position. When retract pressure was applied, the locking device would not 'pop up', it had to be moved manually. The source never left the safe and secure position. The trained radiographer who can work on the locking mechanism decided that the camera would be tagged out and returned to the manufacturer for repair. The camera will be shipped (on today). There was no exposure to the crew or the General Public during this incident. The IR-100 unit uses a 52 Curie Ir-192 source. Source S/N: P311. The licensee has informed Region 4. | ||
| ENS 46051 | 29 June 2010 08:00:00 | 10 CFR 30.50(b)(2) | Source Locking Malfunction of Radiography Camera | On June 29th (at approximately midnight), the radiography crew working the Alpine Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an Industrial Nuclear Corporation (INC) IR-100 exposure device (serial number 6757). During the night shift the locking mechanism tripped prematurely. A survey of the exposure device did not reveal any abnormal readings. When the crank assembly was disconnected it was noted that the pigtail was not in the proper position. A trained technician removed the locking assembly and cleaned dirt from the locking assembly. The exposure device was reassembled with the source in the safe and secure position. There was no exposure to the crew or the General Public during this incident. The IR-100 device uses a 60 Curie Ir-192 source. Source S/N: P344. The licensee has informed Region 4. | ||
| ENS 45669 | 31 January 2010 10:30:00 | 10 CFR 30.50(a) | Radiography Source Failed to Fully Retract Into Camera | On January 31st, two different radiography crews working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on the same INC IR-100 exposure device (serial number 6621). During the night shift, the locking mechanism tripped prematurely (approximately 1/4 inch before the retracted lock position). A survey of the exposure device did not reveal any abnormal readings. When the crank assembly was disconnected, it was noted that the pigtail was not in the proper position. A trained technician removed the locking assembly and cleaned dirt and ice from the assembly. The exposure device was reassembled with the source in the safe and secure position. The day shift utilized the same device and experienced the same situation. When the lock was removed to be cleaned, there was a build up of ice in the locking assembly. The exposure device was reassembled with the source in the safe and secure position. Exposure Device: Industrial Nuclear IR-100; Device S/N: 6621; Source S/N: O835; Source Activity: 85 curies; Source Type: Ir-192. The weather was minus 15 degrees with a wind speed of 18 knots. There was no exposure to the crew or the General Public during this incident. | ||
| ENS 45648 | 22 January 2010 09:00:00 | 10 CFR 30.50(b)(2) | Failure to Fully Retract the Source of a Radiography Camera | On January 22, 2010, a radiography crew working the Alpine Oil Field on the North Slope of Alaska had a camera source that failed to fully retract back into the camera. The technician was able to restore the source to the shielded position and the camera has been returned to the vault. The locking mechanism will be repaired later today. At the time of this report it is believed that the camera contains a 70 Ci Iridium-192 source.
On January 22nd a radiography crew working the Alpine Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device. When preparing to perform the second exposure of the shift (Ir-192, 84 curies) the locking bar deployed prematurely. The crew reset the locking bar and the locking mechanism tripped again when the cranks were rotated. The exposure device was surveyed, no abnormal readings noticed, and prepared for disassembly. When the crank assembly was removed it was noted that the pigtail was not in the proper position, approximately 1/4 inch further inside the camera than normal. The shipping plugs were placed appropriately and the exposure device was tagged out and transported back to the storage vault. When the trained technician attempted to remove the locking assembly, one set screw could not be removed. The remaining set screws were replaced and the camera will be shipped back to the manufacturer for repair. The weather was minus 17 degrees with a wind speed of 18 knots. There was no exposure to the crew or the general public during this incident. Notified the R4DO (Werner) and FSME (Camper).
The report is being updated to provide source and exposure device information. Exposure Device: Industrial Nuclear IR-100 Device S/N: 6761 Source S/N: 0820 Source Type: 82.4 curies, IR-192 Notified R4DO (Pick) and FSME Daytime EO (McIntosh). | ||
| ENS 45609 | 6 January 2010 10:50:00 | 10 CFR 30.50(b)(2) | Failure to Fully Retract the Source of a Radiography Camera | On January 6th a radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device. When returning the source (Ir-192, 108 curies) the locking bar deployed prematurely. The crew reset the locking bar and was able to return the source to the safe and secure position. The crew was working a remote location using a Tucker (tracked machine for traveling over snow) and called for the night foreman. They met at a drill site where the exposure device was reconnected to the drive cables. The source was extended and then retracted. It was noticed that on the return the crank assembly became hard to turn. After the locking bar tripped, the exposure device was surveyed with no noticeable indication that the source was not in the safe and secure position. When the crank assembly was disconnected it was noted that the pig tail was not in its proper position. The exposure device was transported back to the main office. When the lock was disassembled there the technician noted: 'The lock chamber had a reasonable amount of grit coated to the internals.' It should be noted that the exposure device had just been received the day prior. The weather was minus 10 degrees with a wind speed of 10 knots. The lock assembly was cleaned and reassembled as was the crank assembly. There was no exposure to the crew or the general public during this incident. | ||
| ENS 45544 | 7 December 2009 13:30:00 | 10 CFR 30.50(b)(2) | Failure to Fully Retract the Source of a Radiography Camera | Technicians were performing radiography when the source in an Industrial Nuclear Corporation (INC) IR-100 radiography camera was unable to be fully retracted. This was caused by a frozen lock on the device which occurred due to freezing weather conditions. A certified technician serviced the lock. The lock was returned to a fully functional condition, and the source was returned to the safe and secure position. No personnel over exposure occurred. The licensee could not provide the source number of the Ir-192 source at the time of the report. The camera number is 4812. Similar events: EN #45384, 45469, 45524 | ||
| ENS 45524 | 27 November 2009 17:00:00 | 10 CFR 30.50(b)(2) | Failure to Fully Retract the Source of a Radiography Camera | Technicians were performing radiography when the source in an Industrial Nuclear Corporation (INC) IR-100 radiography camera was unable to be fully retracted. This was caused by a frozen lock on the device which occurred due to freezing weather conditions. A certified technician serviced the lock. The lock was returned to a fully functional condition, and the source was returned to the safe and secure position. No personnel over exposure occurred. The licensee could not provide the serial number of the camera at the time of the report due to the remote location where the radiography was taking place. Similar events: EN #45384, 45469, 45496 | ||
| ENS 45496 | 13 November 2009 00:30:00 | 10 CFR 30.50(b)(2) | Failure to Fully Retract the Source of a Radiography Camera | Technicians were performing radiography at the Kuparuk Oil Field in Prudhoe Bay, Alaska when the source in an Industrial Nuclear Corporation (INC) IR-100 radiography camera, serial number 6643 was unable to be fully retracted. This was caused by a frozen lock on the device which occurred due to weather conditions of blowing snow and freezing rain. A certified technician serviced the lock. The lock was returned to fully functional condition and the source was returned to the safe and secure position. The device has a 101 Ci Ir-192 source. No personnel over exposures occurred. | ||
| ENS 45469 | 27 October 2009 08:45:00 | 10 CFR 30.50(b)(2) | Radiography Source Unable to Fully Retract | On October 27, 2009, at approximately 0045 hours local time, in the Kuparuk Oil Field in the North Slope Borough, Alaska, the source in an Industrial Nuclear Corporation (INC) IR-100 radiography camera, serial number 6620 was unable to be fully retracted. This was judged to be due to a frozen lock on the device which occurred due to weather conditions of blowing snow and freezing rain. A certified technician serviced the lock. The lock was returned to fully functional condition and the source was returned to the safe and secure position at approximately 0130 hours. The device has a 60 Ci Ir-192 source. No personnel over exposures occurred. | ||
| ENS 45384 | 27 September 2009 10:00:00 | 10 CFR 30.50(b)(2) | Radiography Camera Source Fails to Fully Retract Into Camera | Technicians were performing radiography at the Kuparuk Oil Field in Prudhoe Bay, Alaska. The IR-100 camera experienced a lockout with the source within the camera but not fully retracted. The technicians were trained on this problem and were able to reset the lockout and fully retract the source. No exposure resulted from resetting the lockout. The IR-100 camera contains less than 100 Ci of Ir-192. | ||
| ENS 43769 | 3 November 2007 23:00:00 | 10 CFR 30.50(b)(2) | Radiography Camera Source Fails to Fully Retract Into Camera | The licensee was using a radiography camera on the Alaska pipeline approximately 50 miles North of Fairbanks (near pump station 7). The temperature was approximately 5 to 8 degrees F. Moisture entered into the locking mechanism causing the latch to trip prematurely i.e. the source was not fully retracted into the camera. The RSO took the latching mechanism apart and fully retracted the source. The RSO and assistant each received a dose of 30 millirem during this repair. Radiography camera: Industrial Nuclear Corporation model IR-100 Source: 72 Curie Ir-192 | ||
| ENS 43117 | 13 January 2007 21:30:00 | 10 CFR 30.50(b)(2) | Failure of Radiography Camera Source to Fully Retract | On January 13, 2006, at 12:30 am local time, while performing a radiography at the facility in Kuparuk, Alaska, the radiography camera source failed to fully retract into the shielded position. The radiographer contacted the Level 2 Radiographer who shielded the camera and was able to fully retract the source. No over-exposures occurred. The camera is a INC Model IR-100, serial number 6631 with a source serial number of J744. The typical original Ir-192 source strength of this type of radiography camera is about 100 curies. Kakivik Asset Management has contacted the manufacturer of the camera about this occurrence and other similar occurrences. | ||
| ENS 43104 | 10 January 2007 18:00:00 | Information Only | Radiography Camera Malfunction | During an equipment checkout prior to use, the ball of the drive cable broke during hookup of the pigtail to the drive cable. The source was locked in the safe position and no exposure was realized due to this incident. The radiography camera is an INC IR100 Model 32 (Serial # 4813) with a 65.8 curie Ir-192 source (serial # J590). The camera will be sent to the manufacturer for inspection and evaluation of the failure. | ||
| ENS 43067 | 28 December 2006 11:30:00 | 10 CFR 30.50(b)(2) | Failure of Radiography Camera Source to Fully Retract | On December 28, 2006, at about 2:30 am local time, while performing a radiography at the pumping facility in Kuparuk, Alaska, the radiography camera source failed to fully retract into the shielded position. The radiographer contacted the Radiation Safety Officer who guided the radiographer in unscrewing the drive cables so that the source was able to be fully retracted. No over-exposures or unplanned exposures occurred. The camera is a INC Model IR-100. The original source strength of the radiography camera Ir-192 source was 100 curies. Kakivik Asset Management plans to contact the manufacturer of the camera about this occurrence. | ||
| ENS 42682 | 8 March 2006 08:00:00 | 10 CFR 30.50(b)(2) | Radiography Source Pigtail Disconnected from Drive Cable | On the evening of March 8, 2006, while performing radiography at an Alpine Oilfield, North Slope Alaska location, Kakivik Asset Management had a source pigtail disconnect from its drive cable on its radiography camera (INC Model IR100 #6621 using an Iridium-192 source). The disconnect occurred after a series of approximately 30 exposures where taken. There where no overexposures. The exposure device (with source) was sent to the manufacturer for an evaluation and disposal. The connector on the drive cable was removed and replaced with a new one. After an examination of the connection by both the RSO and the manufacturer, there appeared to be no obvious conclusion as to why it failed to stay connected. The licensee issued a detailed 30 day report of the incident under 10 CFR 34.101 to Region 4 on April 11, 2006. However, a 24 hour notification under 10 CFR 30.50 to the NRC Headquarter's Operations Center was never made. This report constitutes the licensee's telephone notification of this event. |